Jefferson Journal of

Volume 12 Issue 1 Article 7

January 1994

The Diagnosis of Multiple

Joshua D. McDavid, MD, MPH University of Pittsburgh

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Recommended Citation McDavid, MD, MPH, Joshua D. (1994) "The Diagnosis of Multiple Personality Disorder," Jefferson Journal of Psychiatry: Vol. 12 : Iss. 1 , Article 7. DOI: https://doi.org/10.29046/JJP.012.1.004 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol12/iss1/7

This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Jefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. The Diagnosis ofMultiple Personality Disorder

Joshua D. McDavid, M.D. , M.P.H.

Abstract

This paper represents an att empt to facilitate the clin ician or in making a diagn osis ofMultiple Personali ty Disorder, the most severe ofthe dissociat ive disorders. Emphasis will be placed on detecting signs, symptoms, and information that occur within the consti tuent parts ofa typical psychiatric interview, and that are highly suggestive qfMPD even in the absence ofalter presentation .

Although th e fr equency of th e di agnosis ofMultiple Person ality Disorder (MPD) has incr eased in th e last several years psychiatric resid en cy training progra ms still give little more than cursory attention to this area ( 1,2), a nd as a result, most are not trained in syst ematic ass essment of th e dis sociative diso rd ers. MPD is best con ceptualized as both a com plex, chronic cha rac te rized by disturbance of identity a nd memory (3) and as a post -tra uma tic condition initiating from abuse or traumatic childhood expe rie nces (4) . It has been hypothesized that dissociative states develop as protecti on against overwhelming negative stimuli. Given a necessary biological diathesis, th e pot enti al for autohypnosis or dissociation, th e young, growing, child may form discr ete an d variably "disconnecte d" states wh en confro nted with overwhelming trauma. T hese states a re perpetuated by continuing abus ive or neglecting relation ships, particul arly in th e a bse nce of restorative expe riences with a significa nt ot he r or ot hers (5) . Initially as a kind of " successful" ad aptation, th e dis sociative process insures or increases th e like lihood of t he child's survival. In other dimensions of th e survivor 's life, and especially in adulthood, th e adaptability becom es a disability, impairing the development of a uniform self- con cept and attenuating th e formation of stable interpersonal relationships. The importance of making th e diagnosis of MPD is more th an just a n academic exe rcise . Failure to make th e diagnosis resu lts in substantial morbidity an d even death. Patients who leave treatment prematurely do not cease ha vin g MPD nor do es MPD remit sponta neously (3). Though th e treatment ca n be arduo us, th e potential for resolution of symptoms and improvement of functioning is real. It is not

Joshua D. McDavid, M.D., M.P.H. is an NIMH Clinical Research Fellow a t t he Western Psychi atric Institute a nd C linic of th e University of Pittsburgh.

29 30 J EFFERSO N J O URNAL OF PSYCH IATRY un common for patients with MPD to have been previously diagnosed with schizophre­ nia a nd treat ed as such wit h high dose neu roleptics an d adjuvants; occasionally an MPD patient will be det ect ed in a chro nic ca re faci lity or even th e back wards of a state hospital (6). The purpose of this paper is to aid clini cia ns and psychiatrists in det ecting, primarily in adults, MPD, t he most clinically complex and dramatic of th e dissocia­ tive disorders. Althou gh th e diagn osis of MPD req uires th e identification of alte rn a te personalities (alters) this pap er will highlight th ose a reas with in a typi cal initi al psychiatric intervi ew th at lend th emselves to discovery of MPD in th e absen ce of alter presentation by identifyin g th e sym ptoms cons tituti ng t he polysymptomatic cons te l­ lation fr equently associated with MPD.

DIAGNOSTIC CRITERIA

Besides "the pr esen ce of other personalities" th e DSM-III-R crite ria have not offered mu ch in th e way of guide line s for diagnosin g MPD (7). It has not addressed th e post-traumatic nature of th e disorder, a nd th e only operationa lized crite rio n is one dissociative symptom, person ality change.Because of th e pa ucity of cri te ria a r ticula te d in th e DSM-III-R, clinicians have not learned to inquire in a way th at will ex trica te MPD from other syndro mes. Althou gh th e diagn osis requires th e ide nt ification of dist inct personalities, or alte rs, MPD cons ists of a cons te lla tion of non- specific sig ns a nd symptoms (pol ysymp­ tom atology) and is relatively pleiomorphic (8,9,10, II ). In classic MPD as defin ed by DSM-III-R, each pe rso na lity state, as a dist inc t entity, takes full control of th e person 's beh avior. Cl assic MPD is pr obabl y not as common as less dramatic pr esenta­ tion s with less th an full con tro l and dist inctness (8, 12). Various authors have attempte d to conce ptualize th e subtle gradations, ca lling them at ypical variants, ego state cha nges, co-presences, isom orphi sms, a nd fragments (8, 11,12, 13). DSM -IV cha nges th e name of MPD to Dissociat ive Iden tity Disorder, and it now elimina tes th e requirement of " full" cont ro l as part of th e A criterion.It introduces th e requirement of a m nesia as a cri terion for th e diagn osis since evide nce suggests th at it is a sym pto m in 90% of patien ts with t he disorder. However, wh ether MPD patients expe rience formal a mnesia re mains controve rsial. A new crite rion for th e DSM-IV is: "T he inability to recall important person al informat ion that is too ex te nsive to be ex plaine d by ordina ry forgetfulness" ( 14,15, 16). A fourth criterion stating th at "the disturb a nce is no t du e to a Substance-In duced Disorder" has also been introduce d ( 16). The DSM is not alone in minimally demarcating accompanying signs a nd symptoms of MPD. In the new Intern ational C lassification of , or ICD-I O, MPD has not been list ed formally as a diagnostic entry (17) , but is subsume d und er "other dissociative disorders" (18) . THE DIAGNOSIS OFMULTIPLE PERSO NALITY DISORDER 31

CLINICAL PRESENTATION

General Considerations

The conce pt of "windows ofdiagnosability" has been applied to MPD becau se of its covert ness a nd th e tenden cy of patients wit h th e disord er to dissimulat e (5). Age, ge nder, developmental hist ory, subjective ex perie nces, pr evious experiences with workers, a nd th erapi st ex pe r tise will all influ ence th e express ion of sympto ms during a n int erview. For exa m ple, wh ereas young children may be the most susceptible and least resist ant to early recognition of t he disorder, th eir dissociative sym pto ms appear more vague a nd fr equently seem to have other possibl e diagn oses (15,19, 20). Adolescents seem to be th e most complex and diverse of patients with MPD a nd least likely to reveal alter person alities ( 15). Kluft (8,15) rep orts th at a mo ng adults 20% of th ose with MPD resist det ection; 50% have su st ained periods ofsymptom quiescen ce lasting so metimes a year or mor e; and only a small minority, 6%, are exhibitionistic about th e disord er. In th e conte xt of a risin g suspicion for th e diagnosis, he recommends an ex te nde d interview, since spontane ous symptoms of dissociation may eve ntually eme rge with fatigue and st ress. Ne ver the less, th e diagn osis fr equently requires patience on the pa rt of th e clini cian. Proper diagn osis during th e first intervi ew is th e exc ept ion, an d diagnosis may require weeks, if not months, to det ermine. If MPD is sus pec te d or a polysymptomatic prese ntation occurs, most experi­ e nced clinicia ns recommend t ha t ques tions pert ai ning to t he pr esen ce of alte rs be relegat ed to th e end of th e session once so me rapport has been established (1,9), in orde r not to fri ghten a patient who ofte n will be revealing the mu lti plicity for th e first time to anothe r. These patients often suffer a pr ofoun d sense of personal confus ion, inferiority, and worthless ness and view th e world as fr ightening, overwhelming, and unsy m pa t he tic. Revelation of t he ir internal disorganization to ot hers ca uses great distress (4) .Reluct ance to reveal th e self syste m also may resonate with the child hood fea r of being threat ened or bla med if th ey reveal th e abuse or ofbeing accused as lia rs ( I I). In th e more classic form of MPD th e host or pr imary person ali ty may not eve n be aware of th e presen ce ofalters a nd will den y th eir existence, a nd such a revelation to th e host ca n in itself be traumatic a nd fr igh te ning. If th e patient responds to probing qu esti on s in a pu zzling or out of cha rac te r way, as king if a no the r " pe rso nality" is present is th e prop er in tervention (15) . A negative response, however, may reflect denial a nd not necessarily the absence of MPD. A positive respon se suggests further inquiry given ade quate time a nd recogni­ tion th at th e disclosure could be de-st abilizin g a nd fri ghten ing to th e patient. If a polysymptomatic pr esent ation occurs that is suggestive of MPD th en the clinicia n ca n go farther a nd as k qu estion s about th e pr esence of other "personali ­ ties ." T he presence ofalters usually settles th e diagnosis unl ess th ere is suspicio n ofa malingering or factitious pa tient. Alters are more likely to emerge spontan eou sly when th e patient is in crisis or if th e diagnos is has been made previously (9). 32 JEF FERSON JOURNAL OF PSYCHIATRY

The following qu estions abo ut othe r alte rs ca n be directl y asked: Have you ever been told by others th at you seem like a different person ? Have you ever referred to yourse lf by different names? Or, have you eve r ac te d in a completely different manner? A cave a t to asking questions about MPD is th e real conce rn abo ut iatrogenesis, suggesting or even encouraging th e formation of alternate person alities. Although th ere is some evid en ce th at iatrogen esis ca n occur (3), particul arly as a result of hypnosis, th e clinician must gu ard against being too aggressive as well as being too pa ssive in th e questioning. In st ead of as king patients if th ey have ot her personalities or names, as king abo ut wh ether th ey have other as pects or parts with contradictory or seem ing ly unknown affect s a nd expe riences may help to guard against thi s dil emma.

THE PSYCHIATRIC INTERVIEW

In spite of th e lack of guidelines for diagnosing MPD th ere a re several broad factors that suggest MPD; these factors derive from th e natural loci of th e psychiatric interview though th ey may emerge during a ny ph ase of th erapy. These cons tituents of th e intervi ew include th e history of pr esent illn ess, psychi atric, medical, social a nd developmental history, signs and sym ptoms, a nd th e mental status exa m. Loewenstein ( I) has devised th e "sympto m clus te r meth od" for assessing MPD and Dissociative Disorders. H e divides MPD sym pto ms into six di fferent ph enomeno­ logical ca te gories . Process sympto ms (i.e. switc hing), core aspects of a patient's multiplicity, refer to th ose symptoms that reflect alter transition s or interactions between alters. The other clu st ers a re more familiar, though not necessarily attrib­ ut ed to MPD by clinicians unfamiliar with MPD symptom ex pression. They include , autohypnotic, post-traumatic, somatoform, and affec tive sympto ms . This paper will em phasize th ose aspect s a nd sympto ms of MPD that fall within th e framework ofa traditional psychi atric intervi ew (see tabl e I). Us ually th e clini cian or psychiatrist will not have received any advance direct indication that a patient may have MPD. A compos ite pa ti ent profile that frequently characte rizes t he pr esentation of a " typical" MPD patient is as follows: A 30 year old depressed female with sym pto ms of a m nes ia, recurren t suicidal ideation , self destructi ven ess, a hist ory of sex ual ab use, many psychiatric diagnoses and fail ed treatments. Su ch a profile is unusual in un complicated affective a nd a nx ie ty disorder s and psych osis. Some patients with person ality disord ers, particul arly borderline personal­ ity disorder or a " hys te rical" person ality style ca n a pproach the composite, a nd such a profile wa rra nts conside ra tion ofa nd investigation into th e poss ibility of MPD .

Patient Identification and H istory ifPresent Illness

The sign s a nd sym ptoms of th e composite which j ustify pa rticula r a ttention include a m nes ia without obvious organic ex plana tion, curre nt or past sui cidal or T HE DIAGNOSIS OF MULTI PLE PERSO NALITY DISORDER 33

TABLE 1.

Factors Suggesting MPD that are Part of a Typical Psych iat ric Interview

H istor y of Presen t Illness Sui cide a tt empts Self-mutilation of Self-destru ction " Despe ra te Dep ression" or At ypic al affec tive symptoms Symptoms Amnes ia Fugue Aud ito ry ha llucinations Schneideria n symptoms PT SD Sym ptoms (detachment, avoidan ce, reexperien cin g of trauma, nigh tmares) Concurrent somatic a nd psychiatric symptoms " Hyste ria " Psych iatric Hi story Numerous previous diagnosis a nd treatment fa ilures Prior or Concur rent Disorder: PT SD Borderline personality d isorder Eat ing disorders Psychoti c disorders unresponsive to m edi cations Somatoform disorder Substance or Alco ho l ab use Gender identity disord er Transs exualism or Transvestism Medical History H eadaches Numerous physical com plaints of sexual nature Unexplai ned pa in , particu la rly gyn ecologic or gas tro intestina l Conversion ph enomenon Fear of physical exams or rejection of ca re Family History C haotic family situation Social and Developmental H istory Sex ual, psycho logica l a nd phys ica l abuse, espec ia lly rep etitive and from an ea rly age History of neglect Grossly distorted upbringing and impov erished social network in th e absence of Cult invo lvemen t as a young child Ego-dys tonic sexual impulses and acting out Mental Status Exam Appearance Signs of se lf-injury Behaviors Int ra-interview amnesia Sp ells Spontaneous regression Odd beh avio r despite an apparent rel at edness to the interviewer T he use of "we" Spontaneo us voice or accent changes Sudden invo luntary movements C hanges in fac ia l mu sculature Changes in ha nd ed ness 34 JEFFE RSON JOURNAL OFPSYCHIATRY

TABLE 1.

Factors Suggesting MPD that are Part of a Typical Psychiatric Interview (Cont.)

Flu ctuation s in creative abilities or styles Handwriting cha nges Affect and Mood Dr amatic shifts in a nxiety or mood Thou ght Process and conte nt Pseudod elu sion s Abn ormal self-co nce pt Abnormal body conce pt or image Obsessive ideation Marked ph ob ias Perception s Pseudoh allucin ation Negative hallu cin ation s Schne iderian sym pto ms Illu sions, flashbacks , revivification s Dep ersonali zation/ der eali zation / marked det achmen t Cognition Psych ogen ic a mnesia Abstracti on despi te a ppa rent psych osis

self-destructive behavior, a hist ory of sexua l or ph ysical abuse, an d extensive psychi­ atric hist ory . A symptom profile which includes somatic compla in ts with con comitant psychi atric sym ptoms , or a profile sugge sting Post-Traumatic Disorder (PTSD) with det achment, psychi c numbing, avoidance, incr eased aro usal, an d flashbacks, deserves a ttention. Extreme negative self-evalua tion, disturbance of interpersonal relation ships, com pulsive sex uality, manipulativen ess, reenactments, and adversari ­ ality a re also fre que nt epiphe nomenon of NfPD a nd severe post sexual abuse tra um a (2 1,22).

Psychiatric History

The psychi atric hist ory ca n offer va luable informatio n for cons ide ri ng MPD. The two most import ant indicators a re a hist ory of many prior diagnoses and multiple trea tment failures. Nume ro us psychi at ric hospital izat ions, us ua lly greater th an three, a nd refract or iness to conventional treatment also may reflect undiagn osed MPD. A previous diagnosis of PTSD , borderline personality disorder, ge nde r identi ty disord er, intract a ble su bstance or alco ho l ab use, schizoaffec tive disorder, or sch izo­ phrenia , es pecially in a pa tie nt who a ppea rs to rela te well int erpersonally, does not respo nd to treatment, a nd has a hist ory of sexual abuse sho uld prompt th e clin ician to conside r MPD in th e di fferential diagn osis. T HE DIAGNO SIS O F MULTIPLE PERSO NALITY DISORDER 35

M edical H istory

Numerous ph ysical complai nts often accompany !\,IPD. The most com mon complain t is head ach es. Gastro int estinal a nd sexual symptoms, conve rsion ph enom­ enon, and unexpla ine d pai n syndromes also a re quite com mo n (9). Coon s (6) reported th at 50% of his pa tients with MPD were observed with hyst erical conversion reacti on s. No t un commonly patients will reexperience the physical se nsa tions th at some mist reatment had instill ed with out a ny consc ious awareness of th eir origin (3) . These patients ofte n have chro nic m edi cal illnesses, and they will ofte n not pu rsu e or resist pr op er treatment. Many of th ese patien ts will often fear ph ysical exams a nd a re prone to vasovagal episodes a nd panic attacks eithe r in relation to the exam or venipunc ture. The clinicia n sho uld qu estion a ny patient who demonstrates a marked reluct ance or dread of a ph ysical exam.

Family H istory

Though very non-specific, a pr esent or past chaotic fam ily situation is th e most suggestive indicator of MPD within th e family hist ory. It is not uncommon for th ese patients to have families wit h impoverish ed rela tion ships an d communication net ­ works. H eavy a nd fre que nt , a crimi na l record, sexual, e motiona l, a nd ph ysical a buse , infidelity, divorce, multi-agency involvement , and un employm ent may all be manifest ation s of the chaos. Co nversely, descript ions of " the perfect family" that seem too goo d to be be lievable ra ise suspicion (23) .

S ocial and Developmental H istory

Patients wit h MPD invariabl y have had a grossly distorted upbringing, generally withou t ade quate or consistent support. Interviews sho uld be sensitive to less commonly ide ntified trauma tic experie nces such as long confinements, excessive enemas, a nd med ical procedures occurring at a n ea rly age. Kluft (15) hypothesizes th at most of th ese patients while growing up had no one with whom to sec ure a nurturing bond. Question s conce rn ing abuse and neglect are mandatory parts of an y psychia tric evalua tio n. The presence of ph ysical or sexual abuse invites inquiry into th e pr esen ce of MPD and conversely, the pr esen ce of MPD demands inquiry int o trauma. Attentive obse rva tio n of pa tie nts whil e inquiring about ab use history is very important since man y patients with MPD or an abuse history will "give th emselves away" whe n as ked about th ese a reas.It is not un common to get st ra ng e or unusual a nswe rs to th e qu est ion s or to see incr easin g anx ie ty, a sh udder, tremor, or a startle when discuss ing th ese a reas. Less commonly, dissociative ph enomena su ch as switch­ ing, micro-amnesia, or eve n spo ntaneous alte r emerg ence occurs. It is best not to as k about abuse directl y as this elicit s unwarranted defensiven ess, but an indirect inquiry, like, " How was discipline hand led in your family? How were you punish ed? What was th e worst thing tha t ever happened to you in childhood?" may elicit more ge rmane information. T he evalua tor should conside r alte r na tive qu estions and less direct qu es tions if a negative answer suggests denial. Det ail ed qu estions ab out abuse 36 J EFFERSON JO URNAL OF PSYCHIATRY ca n a nd sho uld be deferred until a more trusting and sustained relationship d evelops. It is important to m ention that during th erapy once a the rapeutic alliance has been es tablishe d question s abo u t abuse d eserve repeated inquiry even if initia l negative responses seemed a ppro pria te. Patients d eny a buse for many reasons: fear, amnesia, or because of misunderstanding abou t the definition of abuse. Finally, a na log ous to th e dil emma di scussed above abo u t as king patients if they have se parate identities and iatrogenicall y ca us ing MPD is the concern abo u t "coachi ng" a patient into admitting, falsely or exaggerating, a history of abuse. Althou gh a lmost too obvious to state, coe rcion a nd eve n suggestion have no place in a psychi atric interview. As import ant as a n abuse history may be to a patient's psych ology a nd behavior it sho uld not be forgotten that a hist ory ofabuse does not by it self imply pathology or MPD, a nd abuse sho uld not be th e th e rapist's primary focu s or agenda without co ns ide ring othe r fact ors su ch as presen ti ng com pla in t, interper­ so nal re la tions hips a nd behavior, a nd the pat ien t 's own perception of the issu es that require focus. It may be impossible to prevent or immediately d et ect the patient who deceives, exaggera tes, or di storts but th e problem ca n be reduced in the conte x t of a se ns itive a nd non-judgmental eva luation, by a clinician wh o ca n call on expe rience and judgment.

Mental Status Exam

Appearance: As a ge neral rul e d uring th e firs t interview MPD patients do not a ppear unusu al or different from the grea t maj ority of pa tien ts. T here is a subset that may appear odd or wear mi sm atch ed or inappropriate clothes. On occasion th e clinician will obse rve ove r t signs of se lf-inj ury. O ver subseq ue n t se ssions curious cha nges in a ppearance may be recognized : significa n tly different styles of clo thing, hair, m ak eup, glasses, pos tu re, and j ewelry. Most of th ese chang es a re su bt le and not dramatic so clinica l se nsitivity to suc h changes will increase th e likelihood of recognit ion ( I). B ehaviors: Facia l changes, body shifts, voice tones, accen ts, cha nge in handedness, eye cha nges, involu nt a ry move m ents, and th e us e of " we " are less subtle signs , a nd are more likely to be ca ptu red during in itia l in terviews . Even so, an initial int erview wit ho ut such behavior is common. Pertin ent beh avioral manifestations ca n occur a ny tim e during the int erview: int ra-in terview amnesia, marked or spontaneou s regres­ sion, spe lls, catato nia, a nd hysteria. These sho uld be suggestive clue s tha t warrant specific qu estions abo ut blackouts, time loss, di ssociation a nd th e ex istence of alters. In the eve n t of th e a ppearance of an a lter, th e focus on th e d iagnosis beco mes pred ominant a nd the reasons for eme rge nce sho uld be explore d. A.ffect and Mood: As mention ed , a frequen t present a tion of MPD is in th e co ntext of a n affec tive illness or anx ie ty disorder. T hou gh affec t and mood changes a rc non-specific, t hey te nd to be exagge ra ted.Dra m a tic shifts in affect during th e interview or between sessions ca n reflect switching behavior. Increasing anxiet y in rela tion to question s co ncerning no n-specific symptoms or abou t MPD directly sho uld raise th e suspicion of th e di agn osis. THE DIAGNOSIS OF MULTIPLE PERSO NALITY DISORD ER 37

Thought Process: In th e conte x t of a crisis pr esentation, a pa tient's st ream of thought ca n be m arked ly loose, rapid, illogical , a nd without goal di rect ed ness. Such th ou ght processes ca n represent rapid alter switching or conflicted "internal dia­ logue" among alters that "spill out" (8,9). At baseline or not in cr isis, MPD patients do not have a formal or thought process dysfunction. Abnormal thought conte nts (pseudod elu sions, , obsessions, abnormal self-conce pts) do occur and a re more likely to persist ove r time. Under usual conditions MPD patients do not suffer or demonstrat e psych otic idea tion. Under severe stress th ey may displ ay " micro-psychotic episodes" simila r to some personality disorders. However, eve n during periods of relative quiescen ce th ese patients oft en display symptoms that clos ely resemble psychotic ideation . Three of th e more com mon pseudodelusions are th e belief th at alters a re se pa rate entities, that on e alter ca n do harm to another without suffering conse q ue nces, a nd that one is being cont ro lled . Often once th e dynamics of th e are underst ood what appears as a del usion usually is a reflect ion of internal conflict a mo ng alte rs , particula rly in relation to th e host or primary person ality (9). Further, these delu sions rarely present as a beli ef that a n exte rnal agency is persecuting t he m or sending th em messages throu gh th e media, sympto ms more com monly see n in true psych oti c illn ess. Similarly, obs ess ive or compulsive ideation or behavior ca n mani fest in MPD and may reflect alt ers in conflict, "ca nce ling out" each others' th ou ghts or be haviors or inserting intrusive thoughts (8) . These patients oft en have sig nifica nt phobias, particul arly in re lat ion to th em es of pr evious trauma. C ertain social situation s, words, objects, or emo tio na l states ca n cue switc hing behavior that may manifest as phobic behavior (9) . Perception: It is not at all unusual for MPD patients to re po rt pe rceptu al disturbances: (better characte rized as pseudoh allucin ations), ne ga tive hallucin ation s, illu sion s, out of body expe riences, a nd dep erson ali za tion a nd dereal­ ization. If th e clinician accepts su ch endorse me nt without furthe r inq uiry, it is easy to confuse th e sym ptoms wit h true psychotic illn ess. Other sympto ms, including severe regressive behavior a nd flash backs or revivifications, ca n be easily confused wit h ca ta tonia a nd visual hallucinations, resp ectively. Schneid erian first -r ank sympto ms a re ofte n reported , e.g., mad e phe nomenon: made impulses, feelings, a nd volition al acts (24) . Patients with MPD ofte n describe hearing voices arguing and making comme nts about th eir th ou ghts (25) .T hese symptoms are better understood as pseudoha llucinations than true loss of reality testing; passive influence ph enomenon and internal voices may represent cove rt conflict a mo ng alters for cont ro l. If amnestic ba rri ers between alters become more fluid th e likelihood of first-rank symptoms ma y diminish (8,9). The following a ppro ac h to a uditory hallucin ation s sho uld be tak en to dissect true psychosis from MPD . Inquiry should focu s on wh ether th e voices reside in the patient's head and wh ether th e voices will speak with th e clinician. Only infrequ ently, about 20% of MPD patients rep ort a udito ry s outside of th eir heads (8). Asking th e patient if it is possibl e to talk to his or her voices ca n lead to emergence of 38 J EFFERSON J O URNAL OF PSYCHIATRY alte rs or give th e clinician so me sense of th e depth of psychosi s. Voices th at are chaotic, incoh erent, or irration al probabl y represent manifestations of psych osis wh ereas alter voices, th ou gh drama tic, ca n be underst ood throu gh dialogue ( 10). Truly psychotic voices resp ond to and will become quiescent for periods of time. The voices of patients with MPD persist and gen erally do not respond to medi cation (9,15). The so called " nega tive sym pto ms" of schi zophrenia usu ally do not cha racte rize MPD (6); however, oddness a nd bizarreness ca n be a tt ribu ted to some alter personali ­ ties. Gen erall y, MPD patients relat e interperson ally m uch bette r than pat ient s with schizophre nia.Perceptual disturban ces suc h as illu sion s, visio ns, flashbacks and revivifications ca n occur during initial eva lua tions or as princip le motivation s for seeking psychiatric ca re if memories, exte rnal cues, or stim uli rekindle images of trauma. Cognitive Exam: The constituents of th e cog nitive exa m-att ention, lan gu age, pr axis, visuospatial fun ctions, calcula tions, a nd a bst ract reasoning-are ge nerally intact in pa tients with MPD (9). Charact erization of memory impai rm ent in t hese patients is com plex. The typ e of amnesia th ey suffer is psychogenic a nd frequently cha rac te rized by asymmetry; th e primary personality is un aware of alte rs bu t not vice versa (4) . Gen erally, shor t term memory a nd memory for skills, inform a tion, fact s, conce pts, and vocabulary, th e so called implicit se mantic memory, remain intact (26), but th ere a re notable exceptions (27), particul arly across alte rs with rigid a m nes tic barriers. Discr et e gaps in lon g term memory, particul arly involving a utobiog ra ph ical materi al and childhoo d events , is com mon. It is important to remember t hat memory deficit s in patients with MPD a re not ge ne rally structural, may be "sta te dependent " to th e trauma, and a re pot entially reversibl e, resolvin g when the anteced ents to the a m nesia a re abreacte d or underst ood (28).

Il\IPRESSIO NS ON THEEVALUATO R

C linicia ns unaccu st om ed to treating or evaluating MPD may find these pa tients perplexing, stra nge, bizarre, or even frightening. It takes time to ge t over th e initial fascination or negative reacti on s that may develop. Since many of these patients present in crisis th e initial conta ct ca n be quite intense. It is not unusu al for clini cian s to experience some of th e dissociative ph enomen on th at th e patien t does, for exa mple, mild intra-interview amnesia or eve n time loss. Such data sho uld be used for ass essment a nd ca n point towards th e diagnosis ( I). In th e author 's expe rience, despite chaotic presentations, most MPD patients relat e well a nd a re likea ble.

ASSESSMENT TOOLS AND INSTR UMENTS

Hyp nosis

Hypnotizabilit y has been documented as a n a tt ribute of and a uto-hypnosis as a pot en tial major fact or of MPD ( 14). MPD pat ients ra pidly and eas ily fall into hypn oti c (tra nce) states, a nd have high scores on mea sures of hypn oti zabilit y THE DIAGNO SIS OF MULTIPLE PERSONALITY DISORDER 39

(28,29,30) . During psych otherapy sessions it is com mon to observe patients ente ri ng what a ppear to be tran ce (hypno tic) states if on ly for br ief periods or seconds. Hypn osis has several a pplica tions in MPD which ca n be divided into th erap eutic an d diagnost ic. The form er uses incl ude relief of anxiety and distress , enabling th e pat ient to use se lf-hypnos is as a way of mast ering int ernal chaos, retrieval of repr essed hist ori cal information , and as a mean s to obtain abreacti ve expe riences (5,9). As a diagn osti c tool hypn osis facilitates emergen ce of alt ers and person ality fragm ents, and sho uld ge ne rally be used only afte r a significant trust has develop ed bet ween a patient a nd th erapist. Hypn osis is most propitiou sly used afte r othe r mean s of making th e diagn osis have been tried a nd so me gro undwor k has been established to prepa re th e patient for wha t ca n be a discon certing or traumatic recognition (30) . Hypn osis of MPD patien ts is ge ne ra lly sa fe and easy to induce but do es require investiga tion int o wh ether th e patient has expe rience d formal hypn osis in th e past , th e qu ality of t hat expe rience, and a n in-depth underst anding of th e patient's curre nt feelings about hypnosis. As with an y diagnosti c or th erap eutic procedure, clearl y a rticulated object ives will ensure a successful outco me . Pr eviou s negative ex pe riences, current misgivings or fears require additiona l ca u tion a nd postpon emen t. Hypn osis is not without un to­ wa rd effec ts. There are rare patients wh o becom e ext re me ly distraug ht or hyst eri cal followin g inducti on. As a rule, early in treatment th e most important principl e is th e contin uity of a therapeu tic allia nce and ensuring the patient's se nse of sec urity. In any eve nt, initially, hypn osis should be use d ca ut iously.

Drug Facilitated Interviews

The use of me dication, eit he r sodium a my tal or sodium pentothal, in diagn osti c in terviews has been described by Putna m (9). Med ica tion s accomplish man y of th e sa me goals as hypn osis but with th e addition of side effects such as sedation. The res traints and precaution s me ntio ne d above for hypnosis, also ap ply to facili­ tat ed interviews. Except for th e patient who refuses, hypnosis shou ld probably be th e procedure of choice .

Self-Report Instrum ents

The Dissociative Experi en ces Scale (DES) is a twenty-eight qu esti on self-r eport screening instrument th at rates dissociative sympto ms a nd experiences (3 1). It is most efficie ntly used wh en given to those patients with suspected dissocia tive sym pto ms or a history of a buse . In th e newly revised ve rsion (32), th e pa tient indicat es ag reeme nt by circling a percentage from 0% (no t a t all) to 100% (all the time). Scoring is calcula ted by taking th e sums of the 28 sco res a nd averaging. The ope ra ting cha racte ristics of th e test have been defin ed using a cutoff of 30 to scre en for cases ofdissociation , giving a sensitivity and specificity of 80% (33) . Patients with MPD ge ne rally score a bove 40, but a high percentage of patients with PTSD and ot her dissociat ive disord ers sco re high er th an 30. A pos it ive score demarcat es the need to pu rsu e a mor e th orou gh evalua tion. 40 JEFFERSO N J OURNAL OF PSYCHIATRY

S tructured Interviews

The Dissociative Disorders Interview Sch edule (D DIS) and the Structured Clinical Interview for Dissociative Disorders (SC ID-D) a re two assessment tools that ca n be used to clarify th e diagn osis. Both are time cons uming, re qu iring from 45 minutes to three hours to com ple te, a nd ge ne rally a re used in resea rch settings rather th an clini cally (9). The DDIS whi ch contains 131 items was developed for the DSM-Ill. It diagnoses dissociative disorders, somatization disorders, major dep ression, and borderline person ality disorder and as ks abo ut childhood se xual abuse. It is reported to have a high se ns itivity and spec ificity for diagnosing MPD (34) . The SCID-D requires sp ecial training, is exte nsive an d time consuming, but is highl y sensitive to MPD a nd abl e to det ect a ll five Dissociative Disord ers (35) .

Biological S tudies

There a re no biological test s th at aid in making th e diagn osis of MPD. Despite a high er than expecte d fr equen cy of abnormal EEGs with non -sp ecific changes (36) , EEGs a re oflittle utility exce pt in differentiating th e case of a patient suspected with partial complex seizures from MPD. Drug scr eens ca n be very helpful in identifying comor bid substance abuse a nd th e occasional patient whose pr esen tation is confuse d with a dissociative disorder.

COMORBIDITY

Como rbid diagn oses exist alongs ide th e primary ide ntified diagnos is, and some­ times th e two nearly overlap (i.e., MPD a nd PTSD). Affecti ve disord ers frequently plagu e patients with MPD a nd a re prin cipal instigators of presentation to the mental health syste m (9,3 7), but do not typically confuse clinicia ns per se; the exc eption to this ge ne raliza tion is bip olar disorder (38). Besid es affec tive disorders, the most com mo n como rbid diagnoses a re anxiet y disorders, subs tance a buse a nd dependence, eating disorders, and person ality disorders. Most expe rts beli eve th at MPD should be treated as a superordinat e diagnosis th at has a plethora of possibl e pr esen tat ions (1,9,15) . Any psychiatric diagnosis may co-exist with MPD (23), but pra ctica lly sp eaking, th e list is finit e.

DIFFERENTIAL DIAGNOSI S

What is most striking abo ut th e differential diagn osis for MPD is t he preponder­ a nce of psych otic sp ectrum disorders in an illn ess th at ge nerally does not exhibit true psych oti c sym ptoms (see tabl e 2). This distinction has to do with th e protean nature of MPD, but is also a reflecti on oflack of training on th e part ofclinicians who are not acc usto me d to cond ucting an int erview for investigating th e diagn osis. THE DIAGNOSIS OF MULTIPLE PERSO NALITY DISORD ER 41

TABLE 2.

Differential Diagnosis of MPD Dissociative Disorders Psychogeni c a m ne sia Psychogeni c fugu e Dissociative di sorder NOS Dep erson ali zation disorder Organi cit y T empor al lobe epilepsy Alcohol Abuse and Dep enden ce Substance Abu se and Dep enden ce Psych oti c Disorders Schizoaffcctive di sorder Bri ef Reactive Psychosis al disorder Mood Disorders Major with psych ot ic features Bipolar disorders Per son ality Disorde rs Borderline person ality di sorder Mix ed Person alit y di sor der Malingering a nd Factitiou s disorder Possession St at es

C ONCLUS ION

As an adaption to sustained sexual, ph ysical, e mo tional a buse or neglect MPD ha s as a conse q ue nce for th e adult profound negative intrapsychi c an d in terperson al effec ts. The expression of th ese effects oft en masquerad es as other psychia tric illne ss. MPD as a polysymptomatic, pleiomorphic, and " hidden" condition is not necessarily easy to det ect and is fr equently denied by patients a nd ove rlooked by clinicians. Because of th e variability of its symptomatic expre ssion it requires patien ce on th e part of th e clinician to diagn ose, bu t th e rewards are significa nt if diagn osis leads to proper treatment disp osition . Question s pert aining to th e non- specific symptoms of MPD mu st now be ask ed of all pa ti ents during th e typi cal psychi atric intervi ew: blackouts, hist ory of sexual and ph ysica l abuse, a nd PTSD symptoms. Other symptoms require additional qu estioning to dissect out th e diagn osis: a uditory hallucin ation s, Schneiderian symp­ toms, a mnesia, and behavioral cha nges. No symptoms a re pa th ognomonic, and it is not always possibl e to mak e a conclus ive diagn osis early in treatment, but th e pr esen ce of a couple of symptoms should raise th e clinician 's ind ex of suspicion. The identification or e me rge nce of alters comes very close to a definitive diagn osis of MPD. In th ose cases that a re suggestive but not definitive th ere arc now several instruments th at ca n facilitat e in th e det ecti on ofdissocia tive processes. While th e focu s has been on the psych ia tric interview and th e symptom expression of MPD in adults , th e importan ce of diagn osis in child re n, who are usu ally 42 JEFFERSON JOURNAL OF PSYCJ-lIAT RY

easier to treat (15), should be em phasized. For many cases MPD can be preven ted altogether by effective child protection interventions. Wh en child abuse has alread y occurred, long term treatment by expe rience d clinician s ca n ame liorate dissocia tive pathology. Prevention and attenuation of traumatic stress disorders, MPD bein g a very severe form, are crucial frontiers of preventive psychiatric medi cin e.

ACKJ'\IOWLEDGEMEi\'T

T he author wou ld like to thank Kathy Reilly, M.A. and Ka th y Pajer, M.D., M.P.H. for t heir helpful comments and suggestions.

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